Epulis: Key Insights on Diagnosis, Management, and Recurrence

Soft tissue growths in the oral cavity can be concerning, especially when they interfere with eating or speaking. Epulis refers to a group of benign gingival tumors that vary in composition and clinical behavior, often requiring intervention based on type and progression. While non-cancerous, these lesions can cause discomfort, aesthetic concerns, and complications if left untreated.

Understanding epulis, its types, and factors influencing recurrence is essential for effective diagnosis and management.

Common Types

Epulis is classified based on histological composition and clinical presentation. Each variant has distinct characteristics influencing growth, symptoms, and treatment.

Fibrous

Fibrous epulis, or fibrous hyperplasia, is the most common type, typically arising from chronic irritation or trauma, such as ill-fitting dental prosthetics or persistent plaque. It appears as a firm, well-circumscribed mass on the gingiva, often pale pink and similar to surrounding mucosa. Histologically, it consists of dense collagenous connective tissue with minimal vascularity, contributing to its slow growth and firm consistency. It is usually asymptomatic unless it interferes with mastication or hygiene. Surgical excision is the primary treatment, with recurrence being rare unless the underlying irritation persists. A Journal of Oral Pathology & Medicine (2021) study noted significantly lower recurrence rates when contributing factors, such as dental restorations, are addressed postoperatively.

Granulomatous

Granulomatous epulis, often called pyogenic granuloma in the oral cavity, is a vascular lesion that develops in response to local irritation or hormonal influences. It grows rapidly and bleeds easily due to its rich capillary network. Clinically, it appears as a reddish, lobulated mass with a soft, friable texture. Unlike fibrous epulis, which remains relatively stable, granulomatous epulis can enlarge quickly, sometimes causing discomfort or functional impairment. Hormonal fluctuations, particularly during pregnancy, contribute to its development, leading to the term “pregnancy tumor.” Histopathological analysis reveals proliferating endothelial cells and inflammatory infiltrates, distinguishing it from other gingival lesions. Treatment typically involves excision, with recurrence more likely if irritants such as plaque or calculus are not controlled.

Ossifying

Ossifying epulis, or peripheral ossifying fibroma, is a more complex gingival lesion due to its potential for calcification and bone formation. It primarily affects young adults and is more common in the anterior maxilla. Clinically, it presents as a firm, sessile or pedunculated mass with a smooth or ulcerated surface, often measuring 1 to 3 cm in diameter. It may appear pink to reddish, depending on vascularity and inflammation. Histologically, it consists of fibrous connective tissue interspersed with mineralized components, including bone trabeculae or dystrophic calcifications. The presence of ossification differentiates it from fibrous epulis and suggests a pathogenesis involving fibroblastic and osteogenic activity. Surgical excision with periosteum removal is recommended to minimize recurrence, which has been reported in up to 20% of cases, according to a review in Oral Surgery, Oral Medicine, Oral Pathology, and Oral Radiology (2022).

Clinical Manifestations

Epulis typically appears as a localized gingival mass, often arising from the interdental papilla or alveolar ridge. Its texture, coloration, and consistency provide diagnostic clues. Some forms are firm and fibrotic, while others are soft and highly vascular, prone to bleeding. Patients may initially notice a small, painless swelling that gradually enlarges, sometimes leading to discomfort if it interferes with mastication or hygiene.

Fibrous epulis blends with adjacent gingiva, maintaining a pale pink hue, whereas granulomatous epulis appears red to purplish due to its dense capillary network. Ossifying epulis may exhibit mixed coloration, reflecting areas of calcification or secondary ulceration. Surface characteristics vary, with some lesions appearing smooth and dome-like while others develop a lobulated contour. Repeated trauma from opposing teeth or dental appliances may lead to surface ulceration, localized pain, and increased infection risk.

Growth rate differs among types. Fibrous epulis enlarges slowly, often remaining stable unless irritation persists. Granulomatous epulis develops rapidly, particularly in response to hormonal changes or chronic inflammation, potentially impairing chewing or speaking. Some patients report episodic bleeding, particularly when brushing or eating, due to the lesion’s fragile vasculature. This symptom is more pronounced in granulomatous forms.

In advanced cases, the mass may exert pressure on adjacent teeth, leading to localized displacement or diastema formation. This is especially relevant in ossifying epulis, where mineralized components create a firmer, space-occupying lesion. Radiographic findings often reveal areas of calcification, indicating a more complex pathophysiology. Some patients experience a sensation of fullness or tightness in the affected region. Although pain is uncommon, discomfort can arise if the lesion ulcerates or interferes with oral function.

Relevant Oral Health Factors

The development and persistence of epulis are closely linked to oral health factors influencing gingival tissue response and lesion progression. Chronic mechanical irritation, often from poorly fitting dental prostheses, sharp tooth edges, or orthodontic appliances, plays a central role. Repeated friction or pressure can lead to localized fibrous overgrowth, as seen in fibrous epulis. Addressing these mechanical stressors through prosthetic adjustments or occlusal modifications reduces lesion formation.

Plaque accumulation and inadequate hygiene exacerbate gingival reactivity, creating an inflammatory environment conducive to lesion development. Bacterial biofilms contribute to chronic gingivitis, increasing vascular permeability and promoting tissue proliferation. Subgingival calculus has been associated with heightened inflammatory responses, particularly in vascular lesions like granulomatous epulis. Studies show that patients with poor plaque control have a higher prevalence of reactive gingival lesions, highlighting the importance of regular cleanings and meticulous home care in preventing recurrence.

Hormonal fluctuations further influence lesion growth, particularly in pregnancy or endocrine imbalances. Elevated estrogen and progesterone levels enhance gingival vascularity and inflammatory susceptibility, making tissues more reactive to minor irritants. Pregnancy-associated granulomatous epulis often regresses postpartum but may persist if irritants remain. While hormones alone do not cause epulis, they amplify tissue responsiveness, accelerating lesion growth in predisposed individuals.

Diagnostic Approaches

Accurate diagnosis requires a combination of clinical evaluation and diagnostic tools to differentiate epulis from other gingival lesions, such as peripheral giant cell granulomas or malignant neoplasms.

Visual Assessment

A thorough intraoral examination provides the first indication of epulis, with clinicians assessing size, shape, color, and consistency. Fibrous epulis presents as a firm, well-demarcated mass, while granulomatous epulis appears more vascular and prone to bleeding. Ulceration, rapid growth, or irregular borders may suggest alternative diagnoses, necessitating further investigation. Sessile or pedunculated growth patterns help determine origin. A comprehensive patient history, including recent dental procedures, hormonal changes, or chronic irritation, aids diagnosis. Clinical photography allows monitoring over time, especially when conservative management is considered.

Radiographic Evaluation

Imaging studies assess lesion extent, particularly when mineralization or bone involvement is suspected. Periapical and panoramic radiographs help identify osseous changes, especially in ossifying epulis, where radiopaque foci indicate calcification. Cone-beam computed tomography (CBCT) provides a detailed three-dimensional view, aiding surgical planning. Though not diagnostic alone, radiographic findings help distinguish epulis from other gingival pathologies, such as odontogenic tumors or reactive bone lesions.

Histopathological Analysis

Definitive diagnosis relies on histopathological examination following biopsy or excision. Tissue samples are analyzed for cellular composition, vascularity, and mineralized elements, classifying the lesion into fibrous, granulomatous, or ossifying subtypes. Fibrous epulis consists of dense collagenous stroma with minimal inflammation, while granulomatous epulis exhibits proliferating capillaries and inflammatory cells. Ossifying epulis contains fibroblastic proliferation with bone or dystrophic calcification. Immunohistochemical staining may be used in ambiguous cases to rule out malignancy. A study in Oral Diseases (2023) emphasized the importance of histopathological confirmation, noting clinical misdiagnosis in up to 15% of reactive gingival lesions.

Management Options

Treatment depends on histological subtype, size, and recurrence potential. While small lesions may remain asymptomatic, surgical intervention is often necessary to prevent enlargement or functional impairment. Complete excision is the preferred approach, ensuring removal of both the lesion and contributing irritants. Simple excision is effective for fibrous epulis, while vascular lesions like granulomatous epulis may require adjunctive techniques such as laser therapy or electrocautery to minimize bleeding. Ossifying epulis requires a more extensive approach, often including periosteum or bone removal to prevent recurrence.

Recurrence

Recurrence depends on excision completeness, persistence of local irritants, and histological characteristics. Fibrous epulis has a low recurrence rate when the underlying cause is eliminated, while granulomatous and ossifying variants pose greater challenges. Incomplete removal is a common cause of regrowth, particularly when deeper tissue layers or associated calcifications remain.

Poor hygiene and chronic gingival inflammation increase recurrence risk, emphasizing the importance of long-term maintenance. Regular cleanings and proper hygiene education reduce the likelihood of regrowth. Hormonal fluctuations, particularly during pregnancy, may contribute to granulomatous epulis recurrence, though these lesions often regress postpartum. Multiple recurrences may warrant biopsy and histopathological reassessment to rule out aggressive reactive lesions or neoplastic processes.